Inappropriate Medicare Advantage care denials appear widespread

A recent report from the HHS Office of the Inspector General (OIG) raises serious concerns about inappropriate Medicare Advantage denials of care as well as wrongful payment denials. It shows that Medicare Advantage plans, commercial health plans that contract with Medicare to deliver Medicare benefits, overturn their own denial decisions 75 percent of the time. Unfortunately, most people do not appeal their denials.

The OIG report suggests that Medicare Advantage plans are likely inappropriately issuing denials many millions of times a year. The data show that only one percent of Medicare Advantage plan members appealed their denials between 2014 and 2016. And, even with such a small fraction of their members appealing, Medicare Advantage plans overturned 532,000 denials of care or payment–three out of four of these denials–over the two-year period.

Put differently, 99 percent of Medicare Advantage plan members, who were denied access to care or payment for services they received, did not challenge their denials. They likely did not understand that they have a right to appeal or that it is an easy process. Had they appealed, there is good reason to believe that three out of four of them would have won their appeals.

– Just Care

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